2017 Student Release Form

You can fill this form out for multiple students if they share the same insurance information. If your students have different insurance information then you will need to fill out the form multiple times.

How many students will you be filling out this form for?

Student Name

First Name Last Name

Student Cell

-
Area Code Phone Number

Date of Birth

-
Month
-
Day Year

Date

Gender

Male Female

Known food/drug allergies

Medication taken regularly

Are immunizations current?

Yes No

Grade

T-Shirt Size

Student Name

First Name Last Name

Student Cell

-
Area Code Phone Number

Date of Birth

-
Month
-
Day Year

Date

Gender

Male Female

Known food/drug allergies

Medication taken regularly

Are immunizations current?

Yes No

Grade

T-Shirt Size

Student Name

First Name Last Name

Student Cell

-
Area Code Phone Number

Date of Birth

-
Month
-
Day Year

Date

Gender

Male Female

Known food/drug allergies

Medication taken regularly

Are immunizations current?

Yes No

Grade

T-Shirt Size

Student Name

First Name Last Name

Student Cell

-
Area Code Phone Number

Date of Birth

-
Month
-
Day Year

Date

Gender

Male Female

Known food/drug allergies

Medication taken regularly

Are immunizations current?

Yes No

Grade

T-Shirt Size

Home Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

In Case of Emergency, Please Contact

Parent/Guardian
*

First Name Last Name

Parent Email
*

example@example.com

Home Phone
*

-
Area Code Phone Number

Cell Phone
*

-
Area Code Phone Number

Family Physician
*

First Name Last Name

Office Phone
*

-
Area Code Phone Number

Friend or Relative
*

First Name Last Name

Phone Number
*

-
Area Code Phone Number

Medical Insurance

Medical Insurance Company

Insurance Phone Number

-
Area Code Phone Number

Policy Number and/or group number

I hereby give my permission for the above student(s) to take part in various church sponsored events. I further give my permission for the church representatives or sponsors of the trips to secure needed medical treatment in the event that I cannot be reached for such permission. I release the church and/or the church representatives or sponsors from liabilty for accident or injuries on the activities.

I further understand and agree that in the event that the above-named student(s) be involved in activities that violate or compromise the rules, policies, or purposes of Woodridge Baptist Church, I will pay and accept full responsibility for release of my child to my custody and care.

I understand that at this event or related activities, my child may be photographed. I agree to allow my child's photo, video, or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers, and assigns.

I understand that my signature conveys the following:

My authorization for the church and its representative(s) to obtain necessary medical treatment for the student(s) listed above

I knowingly release, absolve, indemnify, and hold harmless Woodridge Baptist Church of Kingwood, Texas from all claims that might result from any injury or death of the student(s) listed above

Should medical treatment be required, I agree to pay all medical/hospital care costs, either directly or through my personal health and accident insurance policy.